Community perspectives on the built environment, community stress, and the risk of diabetes and cardiovascular diseases in Accra, Ghana

The growing burden of diabetes and other non-communicable diseases in Africa demands greater understanding of the contextual drivers of risk factors, including the built environment. Cognitive Mapping (CM) is a participatory research approach that allows community members to visualise their environmental context through drawing. The maps express in visual form the situated knowledge of the environment from local perceptions of daily experiences. This study combines Geographic Information System (GIS) techniques and qualitative research methods to explore community perspectives on the environmental risk factors of diabetes and other cardiovascular diseases (CVDs) in a poor urban community in Accra, Ghana. Five Cognitive Map Focus Group Discussions (CM-FGDs) and four regular Focus Group Discussions (FGDs) were conducted with a total of 43 participants in Ga Mashie (Accra) in November and December 2022. Participants (25 women and 18 men) had lived in the study communities for over ten years. Community members were given paper and a pencil for the CM sessions to draw their environment. GIS maps supplemented the community drawings. We adopted geo-ethnography, a technique that combines GIS and qualitative analytical methods. The GIS was used to recreate aspects of the physical environment discussed by study participants. The FGDs were analysed thematically. Participants recognised the physical and social attributes of their daily environment and how these attributes influence the risk of CVDs. Excessive heat and hazardous noise from overcrowded spaces emerged as key health risks. The social environment was equally important – participants often linked the high concentration of bars, spaces for social interaction and several social engagements at weekends to excessive consumption of alcohol and unhealthy food. Community members reported that social behaviour and diet associated with their environments were gradually deteriorating, and these accounted for observed changes in patterns of diabetes and related CVDs. Specifically, community members attributed the causes of hypertension and heart disease to hazardous noise and psychological distress associated with the built environment. In contrast, diabetes was generally attributed to the social environment. Cognitive maps allowed community members to participate in research and link the risk of diabetes and CVDs to their changing environment. Built environment interventions should empower communities to make large-scale behavioural modifications to improve the prevention and control of diabetes and CVDs within their community.